Laserfiche WebLink
SAN .JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOIA+OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ? y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z-114 � <br /> j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2/p-7, i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local.tlealth.DiStrict fC a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br />' <br /> County Ordinance No. 1862 the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION -J.3 C .4 a U IS f A V �• _ CENSUS TRACT <br /> Owner r s Name ��/ J7 C _ Phone " / 77/ <br /> Address 13. 0- Lo V/.S'k 16 V-E City <br /> ° Contractor's Name .. (n ,may R_A' ld �� C U Il C l� License ?,� <br /> hone .?- <br /> TYPE OF WORK (Check).:.--NEW-WELL -DEEPEN /7-�RECUNDiT`If3N 47, DESTRUCTION PUMP REPLACEMENT�T <br /> PUMP :INSTALLATION / I PUMP REPAIR /7 . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/ � SEWER LINESfD�O PIT PRIVY +� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT OTHER (, <br /> `` PROPERTY LINE -- PRIVATE DOMESTIC WELT., - PUBLIC'bOMESTIC WELL �-.- <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION.-SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic%private Drilled Dia. of Well Casing -T- <br /> - DiiCven— - y. Gadige of- asiag _ a <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' � . , _ <br /> Other Other Information ;` <br /> Geophysical o- Surface Seal Installed By: <br /> 'UMP INSTALLATION: . Contractor '"�` <br /> Type: of Pump H.P. �- <br /> # { <br /> PUMP REPLACEMENT: / I State Work Done , <br /> PUMP REPAIR: 4--State Work Done- _ <br /> ESRUCTTON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> rict <br /> 1_9ereby agree to comply with all laws and regulations of the DAYS <br /> San Joaquin Local Health Dist <br /> DAYS <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ditex completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of ttie well and notify them before putting the well in use.. The above <br /> t information,is true to C 'best of my knowledge'; and belief:--l-WILL`CALF FORA GROUT INSPECTION <br /> PRIOR TO Gs UT NG D A AL INSPECTION. '* <br /> SIGNED rf TITLE /- <br /> (DRAW-PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I DATE -/D -77 ._ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: } <br /> PHASE II GROUT INSPECTION pRASY6, III INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 -� <br />